Rationale and key points

A significant proportion of diagnoses are made based on history taking, often alongside physical assessments and laboratory investigations. Taking a thorough patient history is fundamental for the accurate diagnosis and effective management of health conditions. This article outlines a step-by-step process for taking a comprehensive patient history and discusses the evidence for this procedure.

• History taking is a structured but flexible process of gathering relevant information from patients to inform diagnosis and treatment.

• Important communication skills for nurses when history taking include active listening, empathetic communication and cultural sensitivity.

• By actively engaging the patient in a conversation about their health issues, the nurse facilitates their participation and autonomy.

Reflective activity

‘How to’ articles can help to update your practice and ensure it remains evidence based. Apply this article to your practice. Reflect on and write a short account of:

• How this article might improve your practice when taking a patient history.

• How you could use this information to educate nursing students or colleagues on taking a patient history.